Recurrent Ischaemic Stroke in a Patient With Left Ventricular Thrombus Despite Apixaban: Successful Transition to Warfarin

Left ventricular (LV) thrombus is a well-recognised source of cardioembolic stroke, especially in patients with severely reduced LV ejection fraction (LVEF). Anticoagulation is the mainstay of therapy, but the optimal agent remains debated. We report the case of a 68-year-old man with an LV thrombus who suffered recurrent ischemic strokes while on apixaban, with magnetic resonance imaging (MRI) of the brain demonstrating acute infarcts in the left thalamocapsular and occipitotemporal regions. Following multidisciplinary team review, he was transitioned to warfarin with low-molecular-weight heparin (LMWH) bridging, after which he achieved therapeutic international normalised ratio (INR) stability and experienced no further clinically apparent embolic events. This case underscores the ongoing embolic risk associated with LV thrombus despite direct oral anticoagulant (DOAC) therapy, the importance of LMWH bridging when initiating warfarin, and the value of multidisciplinary management in optimising outcomes.